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Alfaheed M, Campos S, Gupta J, Fayyaz J, Litwin S. Stick a Needle in My Eye: A Case Report of Penetrating Needlefish Injury Causing Cavernous Sinus Thrombosis and Carotid Cavernous Fistula. Cureus 2023; 15:e34453. [PMID: 36874751 PMCID: PMC9981213 DOI: 10.7759/cureus.34453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 02/04/2023] Open
Abstract
While swimming in the ocean on vacation in Cuba, a previously healthy 17-year-old female was unexpectedly stabbed through her orbit and into her brain by a needlefish. This is a unique case of a penetrating injury causing orbital cellulitis, retro-orbital abscess, cerebral venous sinus thrombosis and carotid cavernous fistula. After initial management at a local emergency department, she was transferred to a tertiary care trauma centre where she was treated by a team of emergency, neurosurgery, stroke neurology, ophthalmology, neuroradiology and infectious disease physicians. The patient faced a significant risk of a thrombotic event. There was careful consideration from the multidisciplinary team about the utility of thrombolysis or an interventional neuroradiology procedure. Ultimately, the patient was treated conservatively with intravenous antibiotics, low molecular weight heparin and observation. The patient continued to show clinical improvement several months later, which supported the challenging decision to opt for conservative management. There are very few cases to guide the treatment of this type of contaminated penetrating orbital and brain injury.
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Affiliation(s)
| | - Sarah Campos
- Emergency Medicine, The Hospital for Sick Children, Toronto, CAN
| | - Joel Gupta
- Emergency Medicine, The Hospital for Sick Children, Toronto, CAN
| | - Jabeen Fayyaz
- Emergency Medicine, The Hospital for Sick Children, Toronto, CAN.,Faculty of Medicine, University of Toronto, Toronto, CAN
| | - Sasha Litwin
- Emergency Medicine, The Hospital for Sick Children, Toronto, CAN.,Faculty of Medicine, University of Toronto, Toronto, CAN
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Xiong J, Liu H, Li J, Hou J, Cui F. Case report: 18F-FDG PET confirmed pupil-sparing third nerve palsy heralding aseptic cavernous sinus embolism in patient with chest malignancy. Front Surg 2022; 9:893651. [PMID: 36117807 PMCID: PMC9471138 DOI: 10.3389/fsurg.2022.893651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022] Open
Abstract
Classical cavernous sinus embolism is a rare clinical finding, presented most commonly by complaints of headache, diplopia, visual field defects, facial pain, and progressive neurological deficits. Many patients exhibit symptoms of III, IV, and VI nerve palsies. We hereby report a rare case of aseptic cavernous sinus embolism developed in a 75-year-old male with primary lung cancer who presented with binocular diplopia due to unilateral third and sixth cranial nerve palsies with pupil-sparing. The possibility of cavernous sinus cancer embolus should be considered if the routine examination excluded metastases, infiltration, carcinomatous meningitis, or the paraneoplastic process. 18F-FDG PET imaging may provide a promising diagnostic modality for the diagnosis of cancer embolus.
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Affiliation(s)
- Jianmei Xiong
- Department of Neurology, Hainan Hospital of Chinese PLA General Hospital, Hainan, China
| | - Huanbo Liu
- Department of Cardiology, The Second Navy Hospital of Southern Theater Command of PLA, Hainan, China
- Correspondence: Huanbo Liu Fang Cui
| | - Jianyong Li
- Department of Neurology, Hainan Hospital of Chinese PLA General Hospital, Hainan, China
| | - Jiajia Hou
- Department of Neurology, Hainan Hospital of Chinese PLA General Hospital, Hainan, China
| | - Fang Cui
- Department of Neurology, Hainan Hospital of Chinese PLA General Hospital, Hainan, China
- Correspondence: Huanbo Liu Fang Cui
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Kısabay Ak A, Çınar C, Doğan GN, Ataç C, Gökçay F, Çelebisoy N. Clinical improvement in indirect carotid cavernous fistulas treated endovascularly: A patient based review. Clin Neurol Neurosurg 2021; 207:106750. [PMID: 34146840 DOI: 10.1016/j.clineuro.2021.106750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 04/11/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
Patients with indirect carotid cavernous fistulas (CCF) were reviewed to emphasize the importance of diagnosing patients even with trivial findings and to raise awareness. Eighteen patients diagnosed as CCF were included. Neuro-ophthalmological findings before and after treatment, diagnostic investigations, treatment, clinical course was noted. Twelve patients were female (67%), 6 were males (33%) and the mean age at presentation was 54 years (range: 29-70 years). Conjunctival hyperemia was present in all patients. Seventeen (94%) patients had proptosis and diplopia, nine (50%) had orbital pain and/or headache, four (22%) had blurred vision, one (5.5%) had ptosis. On examination, 17 patients (94%) had restricted eye movements, four (22%) had low visual acuity and five patients had (28%) increased intraocular pressure (IOP). One patient had been diagnosed as myasthenia gravis and two as thyroid orbitopathy and had been on treatment accordingly before CCF was diagnosed. In two patients, bilateral findings were present despite unilateral CCF on angiography. Barrow Type B fistula was found in 7 (38%), Barrow Type D in 11 (62%) patients. In three bilateral CCF was detected. All were treated by endovascular intervention. Residual deficits at the sixth month control were, eye movement deficits in seven (39%), decrease in visual acuity in one (5.5%) and elevated IOP in one (5.5%) patient. Indirect CCF patients generally present with mild symptoms and the diagnosis may be overlooked. Mild progressive ophthalmoparesis with conjunctival hyperemia must be warning. Though rare bilateral CCF can be detected as well as unilateral CCF with bilateral findings.
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Affiliation(s)
- Ayşın Kısabay Ak
- Celal Bayar University, Department of Neurology, Manisa 45000, Turkey.
| | - Celal Çınar
- Ege University, Department of Radiology, Bornova, Izmir 35000, Turkey.
| | - Gözde Nur Doğan
- SBU İzmir Atatürk Education and Reseach Hospital, Department of Neurology, İzmir 35150, Turkey.
| | - Ceyla Ataç
- SBU İzmir Bozyaka Education and Reseach Hospital, Department of Neurology, İzmir 35360, Turkey.
| | - Figen Gökçay
- Ege University, Department of Neurology, Bornova, Izmir 35000, Turkey.
| | - Neşe Çelebisoy
- Ege University, Department of Neurology, Bornova, Izmir 35000, Turkey.
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Bernath MM, Mathew S, Kovoor J. Craniofacial Trauma and Vascular Injury. Semin Intervent Radiol 2021; 38:45-52. [PMID: 33883801 PMCID: PMC8049762 DOI: 10.1055/s-0041-1724012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cerebrovascular injury is a potentially devastating outcome following craniofacial trauma. Interventional radiologists play an important role in detecting, grading, and treating the different types of vascular injury. Computed tomography angiography plays a significant role in the detection of these injuries. Carotid-cavernous fistulas, extra-axial hematomas, pseudoaneurysms, and arterial lacerations are rare vessel injuries resulting from craniofacial trauma. If left untreated, these injuries can lead to vessel rupture and hemorrhage into surrounding areas. Acute management of these vessel injuries includes early identification with angiography and treatment with endovascular embolization. Endovascular therapy resolves vessel abnormalities and reduces the risk of vessel rupture and associated complications.
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Affiliation(s)
- Megan M. Bernath
- Medical Scientist Training Program, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sunu Mathew
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jerry Kovoor
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
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Benson JC, Rydberg C, DeLone DR, Johnson MP, Geske J, Brinjikji W, Lanzino G, Cloft H, Luetmer PH. CT angiogram findings in carotid-cavernous fistulas: stratification of imaging features to help radiologists avoid misdiagnosis. Acta Radiol 2020; 61:945-952. [PMID: 31698923 DOI: 10.1177/0284185119885119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Carotid-cavernous fistulas (CCFs) are commonly misdiagnosed on computed tomography angiography (CTA). PURPOSE This study sought to identify the most sensitive and specific imaging features of CCFs on CTA. MATERIAL AND METHODS A retrospective review identified 18 consecutive patients suspected of having a CCF on CTA and subsequently underwent digital subtraction angiography (DSA). Two blinded reviewers assessed multiple findings on CTA: cavernous sinus asymmetry/enlargement; arterial-phase contrast in the cavernous sinus; proptosis; pre- or post-septal orbital edema; and dilated regional vasculature. Each was graded as positive, possible, and negative; "possible" was counted as positive. A third blinded reviewer served as a tiebreaker. RESULTS Of 18 patients, nine were true-positive and nine were false-positive. Superior ophthalmic vein early enhancement and dilatation had 100.0% sensitivity (95% confidence interval [CI] 40.0-100.0) and 77.8% specificity (95% CI 44.4-100.0); arterial-phase contrast in the cavernous sinus had 88.9% sensitivity (95% CI 44.4-100.0) and 66.7% specificity (95% CI 18.5-90.1); peri-orbital edema had 88.9% sensitivity (95% CI 35.5-100.0) and 77.8% specificity (95% CI 22.2-100.0). The most specific markers of CCF were superior petrosal sinus and inferior ophthalmic vein dilatation/enhancement (100.0%, 95% CI 88.8-100.0 and 88.9%, 95% CI 44.4-100.0, respectively); the specificity of asymmetric cavernous enlargement was 44.4% (95% CI 11.1-77.7). CONCLUSIONS Among patients in whom a CCF is suspected on CTA, superior ophthalmic vein dilatation/enhancement and arterial-phase contrast within the cavernous sinus are the most sensitive findings. Asymmetric cavernous sinus enlargement has poor specificity and may result in false-positive diagnoses of CCFs. False positive cases were less likely to have an optimally timed contrast bolus.
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Affiliation(s)
- John C Benson
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
| | | | - David R DeLone
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
| | - Matthew P Johnson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Jennifer Geske
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Waleed Brinjikji
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | | | - Harry Cloft
- Department of Neuroradiology, Mayo Clinic, Rochester, MN, USA
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